s.Ktv425-427] CLINICAL TYPES 103
4.-CLINICAL TYPES
(1)—Major Epilepsy (Grand Mai)
427.] Of the many types of epileptic attack major epilepsy is both the
commonest and the most dramatic. The following is a description of a
typical major attack.
Hpileptic patients frequently exhibit symptoms for some hours or even Pre-
for a day or two before an attack. Mental changes, such as irritability
and depression, abnormal feelings referred to the head, giddiness, and
muscular twitches, are the commonest of these pre-convulsive symptoms.
About 60 per cent of epileptics experience an aura or warning of Aura
the attack. It is a focal symptom due to the beginning of the cortical
epileptic discharge and perceived by the patient before consciousness is
lost. Since the attack may begin at a number of different sites in the
brain there is a corresponding diversity of auras. The aura may consist
of a psychical state such as a feeling as if everything that is being
experienced has happened before, or may originate within the sphere of
the special senses, consisting, for example, of an olfactory or a gustatory
hallucination, a complex visual scene or a flash of light, or the hallucina-
tion of hearing a phrase or word uttered or a loud sound. Somatic
sensibility may provide the aura in the shape of a sensation of numbness,
tingling, or electric shock referred to part of the body. Occasionally
such a sensory aura is painful. A diffuse disturbance of somatic sensi-
bility, such as a feeling of being disembodied, may occur, and peculiar
indescribable visceral sensations usually referred to the abdomen con-
stitute a common form of aura. There are many forms of motor aura,
of which the commonest is a brief spasm or clonic movement such as
rotation of the head to one side or flexion of one upper limb, of which
the patient is aware for a second or two before he loses consciousness.
Vertigo is a common aura, especially in minor epilepsy.
The convulsion may begin with a loud cry, but this is more often Convulsion
absent than present. Consciousness is lost either at the very beginning
of the attack or else immediately after the aura, and if the patient is
standing he falls to the ground often with sufficient violence to injure
himself. Scars on the face from this cause are therefore common in
epilepsy. The first phase of the convulsion proper is a tonic spasm Tonic phase
of the muscles, hence known as the 'tonic phase'. This is usually
symmetrical on the two sides of the body, but it is not uncommon for
the head and eyes to be rotated to one side and for the mouth to be
drawn to one side by asymmetry in the degree of facial spasm. The
upper limbs are usually adducted at the shoulders and flexed at the
elbows and wrists. The fingers are flexed at the metacarpo-phalangeal
and extended at the interphalangeal joints, the thumb being adducted.
The lower limbs are usually extended, with the feet inverted. Owing
to spasm of the muscles of respiration breathing is temporarily arrested
and the patient becomes increasingly cyanosed. The tonic phase lasts